August 2016

Studies examining the relationship between HbA1c and insulin resistance (IR) are conflicting. Glucose measures captured by continuous glucose monitoring (CGM) (e.g. peak glucose, standard deviation, hypoglycemia) in youth have not been explored as predictors of insulin sensitivity (IS). This study assessed the relationship between IS and glycemia in youth with type 1 (T1D) and type 2 diabetes (T2D). Participants in the study included 100 youth with T1D and 42 with T2D. Of these nineteen with T1D and 13 with T2D also wore CGM. It was found that markers of metabolic syndrome and hyperglycemia predicted decreased IS in T2D youth. Paradoxically, hypoglycemia predicted decreased IS in T1D youth, and hyperglycemia, particularly overnight, predicted improved IS. The authors posit that their preliminary results imply different mechanisms underlying IR in T1D vs T2D and suggest a role for non-insulin therapies in T1D to improve IR.http://onlinelibrary.wiley.com/doi/10.1111/pedi.12422/abstract

The introduction to this paper reminds us that sensor-augmented pump therapy (SAPT) with a predictive algorithm to suspend insulin delivery has the potential to reduce hypoglycemia, a known obstacle in improving physical activity in patients with type 1 diabetes. The predictive low glucose management (PLGM) system employs a predictive algorithm that suspends basal insulin when hypoglycemia is predicted. The aim of this study was to determine the efficacy of this algorithm in the prevention of exercise-induced hypoglycemia under in-clinic conditions. It found that SAPT with PLGM reduced the need for hypoglycemia treatment after moderate-intensity exercise in an in-clinic setting.http://online.liebertpub.com/doi/abs/10.1089/dia.2016.0141

Prescribing for Diabetes, England – 2005/06 to 2015/16
NHS digital

Prescribing for Diabetes reports on, and examines prescribing trends on medicines prescribed in primary care in England for the treatment and monitoring of diabetes during the period April 2005 to March 2016. Diabetes is a high profile clinical area, and because the prevalence is increasing the costs associated with treating patients with diabetes are correspondingly increasing. The main findings of this audit were that:

Drugs used in diabetes now make up 10.6 per cent of total primary care net ingredient costs (NIC) and 4.6 per cent of prescription items.

In the financial year 2015/16 there were 49.7 million items prescribed for diabetes at a total net ingredient cost of £956.7 million. Up from 27.1 million prescription items and £513.9 million in 2005/06.

Antidiabetic drugs make up 44.2 per cent of the total £956.7 million net ingredient cost of drugs used in diabetes. 71.3 per cent of prescription items for diabetes.

Type 1 diabetes (T1D) is characterised by autoimmune destruction of pancreatic β cells leading to insulin deficiency. Prompt referral to a specialist paediatric diabetes team (PDT) for insulin initiation and further management is important to prevent diabetic ketoacidosis (DKA), which remains the most common cause of death in this condition. This study recorded the timeliness of referrals from general practitioners (GPs) to PDT, of children suspected of having TID. The investigators surveyed the practice of GPs when they suspect TID in a young person, to ask if they recognised the need for urgent referral to PDT. In addition, they carried out retrospective case notes review of children diagnosed with diabetes mellitus between January 2005 and December 2014. In all 111 out of 300 (37%) of GPs replied to survey. Of these, 73 of the 111 (65.8%) would have referred promptly to the PDT in accordance with National Guidelines. However, 34.2% would have taken an action that would have led to delay in referral to PDT. 96 children were diagnosed with TID during the audit period. There was a delay in referral in 35 (36.5%) children. 19/35 (54.3%) of these children presented with DKA. Mean duration of delay in presentation to the PDT was 1.8 days. In both the survey and the audit, the most common reason for delayed referral was GP attempting to confirm the diagnosis by undertaking further diagnostic tests. The study has usefully identified a modifiable reason for delayed referrals of children with TID.http://pmj.bmj.com/content/early/2016/08/03/postgradmedj-2016-134023.abstract

Acceptability of robot assistant in management of type 1 diabetes in children
Al-Taee Majid A et al. Diabetes Technology & Therapeutics. Doi:10.1089/dia.2015.0428
This study asked the unusual question whether children with type 1 diabetes would accept a humanoid robot as an assistant in their diabetes management. In particular, the study determined how patients felt the robot might contribute to their care and how they responded to advice and education provided by the robot. To examine this a humanoid robot was used in clinic and its acceptability was tested over 3 months in 37 children (aged 6–16 years) with type 1 diabetes during their clinic visits. The results showed that the overall patients’ acceptability was 86.7%. However, the level of acceptability varied depending on the age group; patients aged 6–9 years showed the highest acceptability level of 94.8%, while the older age groups, 10–12 and 13–16 years, showed lower acceptability levels of 85.0% and 83.0%, respectively. There was no difference in the overall acceptability of the robot between the male and female patients (87.0% and 86.5%, respectively). Furthermore, features of the robot that were highly desirable included ability of the robot to give advice on high/low blood glucose (BG) levels (92.0%), how much the patients liked the robot (91.4%), and ability of the robot to give advice on BG patterns (90.6%). In contrast, some other features were found least acceptable such as how likely patients want the robot as a companion (81.0%) and calculation of insulin doses with meals (82.53%). The conclusion was that the use of robots as a new device to support diabetes self-management in children was well accepted by patients.http://online.liebertpub.com/doi/abs/10.1089/dia.2015.0428

In this open access paper, the authors looked at randomised controlled trials with an intervention duration of at least 24 weeks that compared short-acting insulin analogues with regular human insulins in the treatment of adults with type 1 diabetes who were not pregnant. Two review authors independently extracted data and assessed trials for risk of bias, and resolved differences by consensus. They graded overall study quality. They found no clear evidence for a substantial effect of insulin analogues on health-related quality of life. However, there were only few results that were based on subgroups of the trial populations. None of the trials reported substantial effects regarding weight gain or any other adverse events. No trial was designed to investigate possible long-term effects (such as all-cause mortality, diabetic complications), in particular in people with diabetes related complications. The authors concluded that their analysis suggested that only a minor benefit of short-acting insulin analogues on blood glucose control in people with type 1 diabetes. To make conclusions about the effect of short acting insulin analogues on long-term patient-relevant outcomes, long-term efficacy and safety data are needed.http://onlinelibrary.wiley.com/wol1/doi/10.1002/14651858.CD012161/full

The new International Association of Diabetes and Pregnancy Study Groups (IADPSG) recommendations for diagnosis of gestational diabetes mellitus (GDM) are generating discussion regarding their universal adoption. The authors of this paper work in a centre that is currently using stricter GDM diagnostic criteria than those proposed by the IADPSG. They set out to determine the complication rates and antepartum maternal predictors of adverse outcomes in their cohort with mild GDM. A total of 3712 women, with and without diabetes, were included in their retrospective cohort study. It found that the rates of macrosomia and pre-eclampsia were significantly higher in the group with GDM but were lower than the rates usually reported. They claim that their study provides insight into GDM-related complications rates and the benefits of intervention in a large cohort of women with levels of hyperglycemia lower than those currently recommended for diagnosis of GDM. These findings suggest a continuous association between adverse outcomes and maternal hyperglycemia and highlight the important role of maternal risk factors other than glycemic results in the development of pregnancy-related complications. Milder forms of hyperglycemia that would not be identified by IADPSG guidelines may benefit from treatment.http://www.canadianjournalofdiabetes.com/article/S1499-2671(16)30138-1/fulltext

This is the preamble to an open access paper:
Dosing guidelines for patients with type 1 diabetes using continuous subcutaneous insulin infusion (CSII), which are historically based on clinical experience and retrospective studies of patients consuming an American diet, recommend that basal insulin should represent approximately 50 % of the total daily dose (TDD). Recent prospective studies in the USA and Japan conclude that the more appropriate proportion is closer to 30–40 % of TDD. In addition, currently used formulas for calculating the carbohydrate-to-insulin ratio (CIR) and correction factor (CF) may lead to underdosing of bolus insulin by as much as 12.8–50 % for a hypothetical patient. The discrepancies between traditional formulas and data from newer studies can be accounted for by the more rigorous design of the newer studies. International differences in diet composition may also be important to consider when developing dosing recommendations for CSII.

This is an interesting and focused dissertation that will need careful reading.

The concluding statement was:
Further studies are warranted to explore insulin dosing in patients with diabetes, during which meals are controlled and glucose intensely monitored. Ideally, these should be prospective and designed to allow head-to-head comparison of different dosing formulas. This would also provide important information about differences in hypoglycemia or hyperglycemia with different dosing formulas. Finally, regardless of which formulas are used, it is important to emphasize that recommended insulin-dosing formulas are intended as estimates, and should always be tempered with clinical judgment, based upon experience, according to patient-specific factors including diurnal variation in blood glucose and activity level. For example, it is possible that some patients might require more than one CIR over a 24-h period to achieve optimal glycemic control and prevent nocturnal hypoglycemia. Until appropriate studies are published, we believe that new evidence indicates that the following revised formula should be considered as a starting point when initiating a patient with T1D on intensive therapy: TBD = 30–40 % of TDD and CIR = 300–400/TDD.